RAD, Attachment Disorders,
Complex Trauma, etc.
What difference does the name make
and who cares anyway?
Todd Nichols
ATTACh 2007 Conference
Overview

Attachment, Attachment Disorders, and Reactive
Attachment Disorder

Alternative classifications

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
Complex Posttraumatic Disorder
Disorders of Nonattachment
DSM Process
© 2007, Family Attachment Center Inc., www.familyattachment.com
Attachment Terminology Inconsistent

Names still evolving

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Academics
Clinicians
Parents
Effect of confusion


Create terms to fill in
Lots of inconsistent and inappropriate use
© 2007, Family Attachment Center Inc., www.familyattachment.com
Literature Search Results
Words in Article Title
1900-1980
1981-1990
1990-2000
2001-2007
Reactive Attachment
Disorder
Attachment
Disorder(s)
0
1
10
51
0
2
21
59
Databases searched:
CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text
© 2007, Family Attachment Center Inc., www.familyattachment.com
Literature Search Results
Words in Article Title
1900-1980
1981-1990
1990-2000
2001-2007
Reactive Attachment
Disorder
Attachment
Disorder(s)
0
1
10
51
0
2
21
59
Databases searched:
CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text
© 2007, Family Attachment Center Inc., www.familyattachment.com
Posttraumatic
Stress Disorder
1
406
1,778
2,311
Lack of clarity

Some names DO have clear definitions

Important to know definitions that are established and
accepted, particularly when communicating with
various groups
© 2007, Family Attachment Center Inc., www.familyattachment.com
Attachment
John Bowlby, Mary Ainsworth
 Attachment theory articulated between 1940s
and 1970s
 Influenced by Freud and psychoanalysis


Shift in emphasis from internal fantasy life and
psychic processes (psychoanalytic) to real events-nurture, sensitivity, and care
© 2007, Family Attachment Center Inc., www.familyattachment.com
Disciplines that Influenced
Attachment Theory
Psychoanalytic
 Evolutionary
 Ethology

© 2007, Family Attachment Center Inc., www.familyattachment.com
Post-Attachment Fields That
Continue Support
Developmental psychology
 Trauma
 Stress
 Neuroscience

© 2007, Family Attachment Center Inc., www.familyattachment.com
Attachment Classifications
Ainsworth-Strange Situation
 Classifications based on response to stressful
situations. Reunion episode especially important
 Ainsworth classifications
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Secure
Insecure

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Avoidant
Ambivalent
Mary Main and Judith Solomon classification

Insecure Disorganized
© 2007, Family Attachment Center Inc., www.familyattachment.com
Important points about
classifications

Attachment classifications are not clinical
diagnoses

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30% of “normal” population has an insecure attachment
Potential exception is Disorganized Attachment
Classifications may differ depending on dyad

Example

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Child-mother insecure/ambivalent
Child-father secure
So, attachment classification is relationship specific
© 2007, Family Attachment Center Inc., www.familyattachment.com
Practical Implication 1
It is technically incorrect to say a child is “insecurely attached.”
© 2007, Family Attachment Center Inc., www.familyattachment.com
Practical Implication 1
It is technically incorrect to say a child is “insecurely attached.”
The correct phrasing would be to say the child has an
insecure attachment with his (or her) mother, for example.
© 2007, Family Attachment Center Inc., www.familyattachment.com
Attachment classifications

Insecure-Ambivalent

Insecure-Avoidant

Disorganized
© 2007, Family Attachment Center Inc., www.familyattachment.com
Strange Situation Descriptions
Up to
separation
Post
separation
Avoidant
Fails to cry on
separation.
Actively avoids and
ignores parent on
reunion.
Throughout Little or no proximity
or contact-seeking, no
distress, no anger.
Response to parent
unemotional. Focus
on toys or
environment.
Ambivalent
Wary or distressed even
prior to separation, with
little exploration.
Fails to settle and take
comfort in parent upon
reunion, usually continues
to focus on parent and cry.
Fails to return to exploration
after reunion.
Preoccupied with parent
throughout procedure; angry
or passive.
Disorganized
Displays disorganized
and/or disoriented behaviors
in parent’s presence,
suggesting temporary
collapse of behavioral
strategy. May freeze with a
trance-like expression,
hands in air. May rise at
parent’s entrance, then fall
prone and huddles on floor,
or may cling while crying
hard and leaning away with
gaze averted.
Source: Hesse, E. (1999). The adult attachment interview: Historical and current perspectives. In J. Cassidy and
P. R. Shaver (Eds.), Handbook of Attachment: Theory, Research and Clinical Applications (pp. 395-433).
New York: Guilford Press.© 2007, Family Attachment Center Inc., www.familyattachment.com
Reactive Attachment Disorder

Clear, but evolving, definition

First appeared in DSM III 1980

Differentiate from nonorganic Failure to Thrive
 Required condition of failure to thrive

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Required inappropriate social relatedness in most contexts
Required onset prior to 8 months
 inconsistent with developmental literature, which says kids form
selective attachments between 6 and 12 months
© 2007, Family Attachment Center Inc., www.familyattachment.com
Reactive Attachment Disorder

Major revision in DSM-III-R in 1987

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Dropped failure to thrive requirement
Age of onset modified to first 5 years
Inhibited and disinhibited types added
Pathogenic care requirement
DSM IV 1994
 Next DSM Revision expected 2011

© 2007, Family Attachment Center Inc., www.familyattachment.com
Criticisms of R.A.D.
Not based on attachment (child-caregiver)
relationship
 Maltreatment syndrome
 Requirement of inappropriate social relatedness
in most contexts
 Only appropriate for kids with NO selective
attachment

© 2007, Family Attachment Center Inc., www.familyattachment.com
Practical Implication 2
© 2007, Family Attachment Center Inc., www.familyattachment.com
Attachment Disorders
There is a large group of children with significant
clinical features related to disordered attachment
relationships who are not captured by current
diagnostic classifications
 Attachment-exploration balance
 Secure base and safe haven

© 2007, Family Attachment Center Inc., www.familyattachment.com
Alternative Classification Systems

Lieberman, Zeanah, Boris, and others

Disorders of nonattachment

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Secure base distortions

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With emotional withdrawal
With indiscriminate sociability
With self-endangerment
With inhibition
With vigilance/hypercompliance
With role reversal
Disrupted attachment
Source: Zeanah, C. H. & Boris, N. W. Disturbances and disorders of attachment in early childhood. In
C. H. Zeanah (Ed.), Handbook of Infant Mental Health, 2nd ed. (pp. 353-368). New York: Guilford.
© 2007, Family Attachment Center Inc., www.familyattachment.com
Continuum of attachment levels
Source: Boris, N. W. & Zeanah, C. H. (1999). Disturbances and disorders of attachment in infancy:
An overview. Infant Mental Health Journal, 20, 1-9.
© 2007, Family Attachment Center Inc., www.familyattachment.com
Alternative Classification Systems

Complex Trauma-dual problem

Children’s exposure to traumatic events

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Multiple traumatic events that occur within caregiving system,
which is supposed to be the source of safety and stability
Simultaneous or sequential occurrences of maltreatment-emotional abuse and neglect, sexual abuse, physical abuse,
witness domestic violence--that are chronic and begin in
early childhood
Initial exposure puts individual at elevated risk for
subsequent exposure
Source: Cook, A., Blaustein, M.. Spinazzola, J., & van der Kolk, B. (Eds.). (2003). Complex Trauma
in Children and Adolescents: White Paper from the National Child Traumatic Stress Network
Complex Trauma Task Force. National Child Traumatic Stress Network: Los Angeles.
© 2007, Family Attachment Center Inc., www.familyattachment.com
Alternative Classification Systems

Complex Trauma-dual problem (cont.)

Impact of exposure on long term outcomes

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Range of clinical symptomatology after such exposure
Multiple domains of impairment

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Attachment
Biology
Affect Regulation
Dissociation
Behavioral Control
Cognition
Self-Concept
© 2007, Family Attachment Center Inc., www.familyattachment.com
DSM Focii
Unite DSM and ICD classifications
 6 initial focus area-White papers
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Basic nomenclature issues
Basic and clinical neuroscience and genetics
Advances in developmental science
Personality and relational disorders
Mental disorders and disability
Cross-cultural issues
3 additional focus areas added
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Gender
Geriatric
Infants and young children
Source: dsm5.org
© 2007, Family Attachment Center Inc., www.familyattachment.com
DSM V Timeline-Publication 2011
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Formal Revision
White papers
Publish
Research
Agenda
Conferences
Begin
Task Force
Appts.
Planning Stage
2009
Workgroups
© 2007, Family Attachment Center Inc., www.familyattachment.com
DSM Task Force
David J. Kupfer, M.D. chair
 Darrel A. Regier, M.D., M.P.H. vice chair
 Chairs of 20-25 work groups plus others

© 2007, Family Attachment Center Inc., www.familyattachment.com
Task Force Members
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William Narrow, M.D., M.P.H., research director, DSM-V Task Force
Maritza Rubio-Stipec, Sc.D., statistics and methods director
William T. Carpenter Jr., M.D., chair, Psychosis Work Group
Francisco Xavier Castellanos, M.D., chair, Externalizing Disorders
Wilson M. Compton, M.D., M.P.E.
Joel E. Dimsdale, M.D., chair, Somatoform Disorders Work Group
Javier Escobar, M.D., M. Sc.
Jan Fawcett, M.D., chair, Mood Disorders Work Group
Steven E. Hyman, M.D., rapporteur, Spectra Study Group
Dilip Jeste, M.D., chair, Dementia, Delirium, Amnestic & Other Cognitive
Disorders Work Group
Helena C. Kraemer, Ph.D.
Daniel T. Mamah, M.D., M.P.E.
James McNulty, A.B., Sc.B.
© 2007, Family Attachment Center Inc., www.familyattachment.com
Task Force Members
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Howard B. Moss, M.D.
Charles O'Brien, M.D., Ph.D., chair, Substance-Related Disorders Work Group
Roger Peele, M.D.
Katherine A. Phillips, M.D., chair, Anxiety Disorders Work Group
Daniel Pine, M.D., chair, Childhood/Adolescent Disorders Work Group
Charles F. Reynolds III, M.D., Ph.D., chair, Sleep Disorders Work Group
Andrew E. Skodol II, M.D., chair, Personality Disorders Work Group
Susan Swedo, M.D., chair, Autism & Other PDD Work Group
B. Timothy Walsh, M.D., chair, Eating Disorders Work Group
Philip Wang, M.D., Dr. P.H.
William Womack, M.D.
Kimberly A. Yonkers, M.D., rapporteur, Gender & Cross-Cultural Study Group
© 2007, Family Attachment Center Inc., www.familyattachment.com
Family Attachment Center
18322C Minnetonka Blvd
Deephaven, MN 55391
952-475-2818
www.familyattachment.com
© 2007, Family Attachment Center Inc., www.familyattachment.com